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Abstract

Objective

To evaluate the association between the consumption of unhealthy foods in children
under one year and the education level of the mothers, data obtained from participants
of the II Survey on the prevalence of breastfeeding in the Brazilian capitals and
the Federal District in 2008 was analyzed.

Methods

During the second stage of the campaign for multi-vaccination, a questionnaire on
food consumption in the last 24 hours was given to mothers or guardians of children
under one year old. We analyzed the consumption of unhealthy foods according to age
group, maternal education, region of residence and breastfeeding status. The state
capitals and the Federal District were grouped according to the five macro-regions
of the country (North, Northeast, Southeast, South and West). Processed juice, soda,
coffee, cookies/salted snacks and sugar and/or honey were defined as unhealthy foods.
Prevalence ratios (RP) for the association between the consumption of unhealthy foods
and maternal education were estimated using Poisson regression models. Results: The
study included 34,366 children. The consumption of sweet foods started early and was
predominant until the age of six months; after this age, the consumption of biscuits
and/or snacks became more prevalent. The consumption of these foods also differs in
relation to the macro-region of residence. Consumption of unhealthy foods was higher
among mothers with lower education levels.

Conclusions

The consumption of unhealthy foods by Brazilian children under one year old was high,
indicating a need for developing effective strategies to combat the consumption of
unhealthy foods in Brazilian children as a way of preventing obesity and other future
disorders.

Keywords:

Supplementary feeding; Food habits; Infant; Cross-sectional study

Introduction

In recent decades, a significant increase in the prevalence of obesity has occurred
worldwide mainly in developing countries [1]. Approximately 43 million children under 5 years old are overweight or obese, and
80% of these children are living in developing countries [2]. In Brazil, data from the National Demographic and Health Survey in 2006 indicated
that 7.3% of children under 5 years old are overweight [3]. Data from the Household Budget Survey (POF/2009) [4] showed that one in three children between the ages of 5 and 9 years old were overweight
according to the World Health Organization guidelines [5]. The development of obesity during infancy and early childhood is associated with
rapid infant weight gain, infant-feeding practices, sleep duration, the child’s diet,
physical activity, sedentary practices and racial/ethnic differences [6]–[8]. Despite the inability of the authors to demonstrate a clear association between
the age when solid foods are introduced and obesity, the conclusion of a systematic
review examining the association between the timing of solid food introduction and
obesity during infancy in developed countries recommended that a whole family approach
to obesity prevention is the most effective [9].

In this context, it is essential to promote healthy eating habits early in life, which
includes exclusive breastfeeding (EBF) during the first six months of life and, after
this age, the introduction of appropriate complementary feeding (WHO,2003) [10]. EBF is relatively uncommon worldwide; only 36% of infants from 46 developing countries
are exclusively breastfed, less than one-third of children between the ages of 6 and
23 months meet the minimum dietary diversity, and only 50% of children receive the
minimum number of meals [10]. Data from the study of African-American infants and young children participating
in the US Infant Care and Risk of Obesity Study show that the rates of inappropriate
feeding age are high and are associated with a higher daily energy intake and an increased
odd of high infant weight-for-length [11]. A systematic review examining the types of foods introduced during complementary
feeding and the risk of childhood obesity showed that higher energy intake during
complementary feeding was associated with a higher Body Mass Index (BMI) in childhood
[12].

In Brazil, despite advances, data from the Second National Survey on the Prevalence
of Breastfeeding (PPMA II), which was conducted in all Brazilian capitals and the
Federal District in 2008, showed that only 41% of children ages zero to six months
were exclusively breastfed. Regarding complementary feeding, the survey found that
21% of children between the ages of 3 and 6 months experienced an early introduction
of foods, and, even more alarming was the finding that these children consumed a large
amount of unhealthy foods such as cookies, snack foods and soft drinks during their
first year of life (MS, 2009) [13].

There is some evidence concerning the association between parental education and the
consumption of unhealthy foods. The IDEFICS cohort study in Europe analyzed data from
children aged 2 to 9 years old and showed that low parental education level was associated
with higher intake of sugar-rich and fatty foods among children, while high parental
education levels were associated with higher intake of low-sugar and low-fat foods
[14]. However, the studies conducted in less affluent parts of the world focused primarily
on the risk of undernutrition, and very few studies addressed the determinants of
obesity [15]. Moreover, most of the studies conducted in this field focus on preschool and school
age groups, indicating that factors in early childhood (< one year) could be important
for understanding the determinants of obesity in later life and provide insights into
the importance of adequate nutrition during early life in obesity prevention.

Considering the heterogeneity of the educational level in Brazil and the availability
of data from the large survey conducted in PPMA II, we designed the present study
to evaluate the association between the mother’s education level and the consumption
of unhealthy foods among children younger than one year old.

Methods

For this study, we utilized the data contained in the database of the Ministry of
Health on the PPMA II, which was conducted in all state capitals and the Federal District
during the second stage of the multi-vaccination campaign in 2008 [13]. Survey samples were obtained in clusters with two-stage draw with a probability
proportional to the size of the group. The sampling plan was based on information
from the 2007 vaccination campaign, which was provided by the Municipal Health Department
of the capitals and the Federal District, and a survey conducted in 1999 provided
information regarding the prevalence of EBF in these places [16]. First, the vaccination posts in each capital were selected, and then, the number
of children in each cluster (post) was selected.

The data collection instrument included closed questions about the dietary intake
of the children. The interviews had to be conducted quickly so as not to interfere
with the vaccination campaign. Therefore, most questions pertaining to feeding were
dichotomous (yes/no) Questions about breastfeeding and consumption of liquids other
than human milk (water, tea, milk powder, milk box, fruit juice) were collected to
characterize breastfeeding practices; the types of food consumed (porridge, mash,
soup, homemade food, fruits, vegetables, meat, beans) were included to analyze the
introduction of complementary foods and some unhealthy foods, commonly consumed in
Brazil and not recommended by the Ministry of Health’s guide for infant feeding under
2 years (soda, processed juice, coffee, cookies/salted snacks, foods sweetened with
sugar or honey) were introduced as markers. The instrument follows the WHO recommendations
for obtaining indicators on infant feeding practices in population studies, such as
using current data (current status) via 24 h recall that aims to minimize possible
recall bias [17]. Characteristics of the children and mothers were collected to examine associations
between personal characteristics and feeding practices. Trained interviewers administered
the questionnaires to all mothers or caregivers of children less than 12 months of
age. Those responsible for research in the municipalities typed the data into an application
online. The database was exported and analyzed using Stata 10.1 Stata Corp LP, Texas
USA and the charts and tables were prepared using Microsoft Office Excel 2003.

Specific procedures for data analysis from complex probability-sample surveys were
used to obtain descriptive statistics. We analyzed food intake according to: the age
of the child (0–6 and 6–12 months); maternal education: college (≥13 years of study),
high school (between 10 to 12 years of study), elementary school (up to 9 years of
study) and no schooling; the region of residence (North, Northeast, Southeast, South
and Center-West); and breastfeeding status. Next, we estimated the prevalence ratios
(PR) for the association between the consumption of each unhealthy food and maternal
education, using unhealthy food consumption as a “proxy” for socioeconomic status,
which would directly influence care during childhood [18]. The significance of the associations between unhealthy food consumption and the
information obtained by the questionnaire was verified by conducting a Poisson regression
with robust variance for complex samples, as recommended for cross-sectional data
with non-rare outcomes [19].

We considered the indicators of unhealthy food consumption in the day before the interview
the dependent variable. The following foods were classified as unhealthy: processed
juices, soda, coffee, cookies and/or salted snacks and sugar and/or honey. The main
independent variable was maternal education (college education, high school, elementary
school and no education); additional explanatory variables were also considered, such
as: the “age of the child” in days; “maternal work” (work outside the home, no work/maternity
license); “maternal age” (<20 years, 20–34 years, ≥35 years); “breastfeeding” (yes,
no); region of residence (North, Northeast, Midwest, Southeast, South). The independent
effect of explanatory variables with a significance level of ≤20% on chi-square testing
was adjusted in the multiple regression models.

The Ethics Committee of the Institute of Health approved this study’s protocol (protocol
001/2008 of 06/05/2008) after consulting with the National Commission for Ethics in
Research (CONEP).

Results

This study included 34,366 children, and their characteristics are presented in Table 1. The majority of the interviews were conducted with mothers (88%), whereas fathers
were interviewed in 7.6% of the cases. In the remaining cases, the relative responsible
for the child completed the interview.

Table 1.Characteristics of mothers and children under 1 year of age in the Brazilian capitals
and the Federal District, 2008

Table 2 shows the frequency of unhealthy food consumption by age, region of residence and
breastfeeding status. We verified that the consumption of sweetened foods began early
and was predominant during the first six months of child’s life; after this age, the
consumption of cookies and/or salted snacks was more prevalent. Over 70% of children
between the ages of 9 and 12 months consumed cookies and/or salted snacks on the day
before the interview.

Table 2.The frequency of unhealthy food consumption by age group, breastfeeding status and
region of residence in children under 1 year of age in the Brazilian capitals and
the Federal District, 2008

The consumption of unhealthy foods also differs between regions of residence. The
consumption of processed juice, soda and coffee occurred less frequently in the Northeast.
Additionally, a higher consumption of cookies and/or salted snacks was observed in
the South, and a higher consumption of sweetened foods was observed in the Northeast.
It was also found that breastfed children under one year old received unhealthy foods
less frequently compared to children who were not breastfed (Table 2).

It is important to notice that a greater consumption of unhealthy foods does not necessarily
imply that other types of foods were not being given to the children. Vegetables and
fruit consumption was influenced by maternal education as well. Mothers with college
degrees gave their children more fruits and vegetables than mothers with only high
school or elementary school educations (p = 0.001). Interestingly, the differences between the highest and the lowest education levels
were not significant for healthy foods, which was in contrast with the findings obtained
for unhealthy foods (data not showed).

Figure 1 shows the frequency of unhealthy food consumption by children under 1 year old according
to maternal education, which indicates that the higher the mother’s education level
the lower the consumption of unhealthy foods. Children of mothers with no formal education
consumed twice as much processed juice, soft drinks and coffee compared to the children
of mothers with college degrees.

Figure 1.The frequency of unhealthy food consumption according to the mother’s educational
level in children between the ages of 0 and 12 months in the Brazilian capitals and
the Federal District, 2008.

Table 3 shows the crude and adjusted analyzes of the association between unhealthy food consumption
and maternal education. The consumption of processed juice, coffee and sugar and/or
honey was negatively associated with the educational level of the mother. Children
of uneducated women consumed between 2 and 3 times more of these foods more frequently
when compared with children of women with higher education levels. The consumption
of soft drinks and cookies and/or salted snacks was highest among children of women
with only an elementary education. It is important to notice that the rates of unhealthy
food consumption across the different education levels were not markedly different
after adjusting for other possible confounders. These findings indicate that the association
between unhealthy feeding and a mother’s lower education level is robust.

Table 3.Estimates of the prevalence ratio, tendency (p) and confidence intervals (CI95%) by crude and fitted analyses for the association
between the unhealthy food consumption and maternal education level, 2008

Discussion

The results of this study showed that unhealthy foods are present in high frequency
in the diets of children under one year old and that this behavior is associated with
low maternal education. These results are consistent with the findings of other studies
on infant feeding conducted in Brazil as well as those of studies in other countries
[20,21].

The presence of unhealthy foods in the diets of children was analyzed in three studies
in the state of São Paulo. A survey conducted in 136 counties detected that 63% of
children between 6 and 12 months consumed porridge, which, in most cases, has sugar
added during the preparation [22]. In the city of São Paulo, a study revealed that the introduction of food occurs
before 6 months of age especially sweets, and that 69% of children consumed soft drinks
at 12 months of age [23]. Additionally, in the city of São Paulo, a study on a random sample of children from
birth to 59 months showed that family income influenced the consumption of processed
foods, and the children from families with lower incomes were more likely to consume
sugar [24].

The consumption of unhealthy foods has also been demonstrated in children under five
that are beneficiaries of Bolsa Família (Brazilian program of cash transfers for families
in poverty and extreme poverty) in the Brazilian semiarid region. These children were
three times more likely to consume sweets than children not receiving this benefit,
which suggests that income and maternal education may have an important influence
on food choice [25].

Weaning represents an opportunity to promote lasting dietary habits. An optimal transition
from milk to healthy table and family foods will help to establish healthy eating
habits that may affect food preferences into adulthood [26]. Therefore, this period may be considered one of the determinants of healthy eating
habits, which, ultimately, may prevent diet-related diseases [27].

In countries such as The United States, infants and young children obtain most of
their nutrients from infant formulas and/or fortified cereals and other fortified
foods. While these foods provide a substantial proportion of a child’s micronutrient
requirement, there are some indications that excessive intake of these types of foods
should be avoided [28]. Overweight and obese children are a public health problem, and diets that exceed
dietary guidelines for fat, cholesterol, added sugar, saturated fatty acids and sodium
and are low in fiber must be avoided to prevent diseases [29]. The consumption of sugar is associated with dental caries [30] and a higher risk of developing childhood obesity [31,32]. In addition, low quality diets may cause micronutrient deficiencies due to their
lower nutrient content when compared to products lower in sugar [33,34]. Excessive salt intake during childhood increases the risk for cardiovascular disease
in adulthood. High sodium intake during the first 6 months of life has been associated
with higher blood pressure [35-37]. Therefore, excessive exposure to early obesogenic diets may also influence appetite
regulation and the ability of the hypothalamic neural circuit to regulate appetite
by inducing permanent changes in the complex pathways that link the hypothalamus,
gastrointestinal tract and adipose tissue [38]. These findings reinforce the importance of promoting healthy nutritional habits
during childhood.

In Brazil, the prevalence of breastfeeding and exclusive breastfeeding, though still
below the levels recommended by the WHO, has been gradually increasing in recent decades,
as a result of major advances by the National Program to Encourage Breastfeeding (PNIAM)
to promote breastfeeding since it was founded in 1981 [39,40]. However, public strategies to promote healthy complementary feeding were adopted
much more recently [41]. Examples of these strategies are in the publication of “Dietary Guidelines for Children
Under Two Years - Ten Steps to Healthy Eating” in 2002 (revised in 2010) [42] and the formulation of the National Strategy for Healthy Complementary Feeding (ENPACS)
[43], which aim to support and promote healthy infant feeding at the primary health care
level.

This study confirmed that children under one year consume high amounts of ultra-processed
foods such as biscuits and soft drinks. It is important to know the deleterious effects
of these foods. Because they are formulated to be durable, affordable and easy to
eat, they contain excessive amounts of oils, fats, flour, starch, sugar and salt,
as well as preservatives, stabilizers, flavorings and colorings. They feature high
energy density, low nutritional value and scarcity of fiber, which are all characteristics
that increase the risk for obesity, diabetes and cardiovascular disease [44,45].

An association between unhealthy food consumption in children and socioeconomic status
of their families was also found in developed countries. In Bristol, UK, an inverse
relationship between maternal education and the consumption of unhealthy foods, such
as sausage and burgers, by 10-year-old children was found; and, in contrast, there
was a positive relationship between the consumption of fruits and vegetables and maternal
education [46]. In California, United States of America, a study conducted among parents of children
who attended a school for low-income families showed that the most common barriers
to healthy food consumption were their high cost and the ease of access to fast food.
Furthermore, it was shown that many parent’s basic knowledge about nutrition came
primarily from television, radio, magazines and newspapers, demonstrated that they
were easily influenced by the media [47].

In a population-based cohort study with Brazilian children, it was found that maternal
education has an effect on a child’s health, which is partly independent from that
of other socioeconomic factors; it was also suggested that maternal care is more important
than the biological characteristics of the mothers, because stronger effects were
observed for a child’s health outcome later (post neonatal mortality, hospital admissions
and nutritional status) rather than earlier (birth weight, perinatal mortality) [48].

The high consumption of unhealthy foods in children less than one year old is most
likely a reflection of changes in food expenditures in the Brazilian population, which
was identified by the Household Budget Surveys (HBS). For example, among the products
that showed an increase in the average per capita amount purchased, cola soft drinks
occupied a prominent place, which grew by 39.3% between 2002–2003 and 2008–2009 [49]. Another important finding of this survey was that out of the 1,792 kcal available
for each person on average, approximately 20% of the kcal come from products considered
to be ultra-processed, while 38% of the kcal comes from processed foods [50].

We agree with Victora et al. [48] when they say that the main challenge is how to educate parents to provide healthy
nutrition habits for their children, especially in a situation where the parents are
undereducated or have deep-seated cultural values. The parent’s attitude towards eating
is a determinant of their children’s future diets, and it influences their feeding
habits and, consequently, their risk for diet-associated diseases.

One of the major limitations of this study is related to the use of the 24-hour recall
with closed questions, which cannot investigate the amount consumed, the frequency
of consumption or the introduction of foods into the diet of infants.

This study gave an important contribution to quantify, at a national level, some feeding
practices in young children. The results serve as a warning to health professionals,
managers and society about the need for developing effective strategies to tackle
unhealthy food consumption among Brazilian children as a way to prevent obesity and
other health problems in the future. It is hoped that the newly launched strategy
“Breastfeeding and Feeding Brazil”, aimed at promoting healthy eating habits early
in life at the primary health care level, can help address this important public health
problem. Other measures, such as regulating food advertisements, which already occurs
with products designed to substitute breast milk [51], has been widely debated by researchers, scientific societies, professional associations,
consumer organizations and civil societies in general.

Conclusion

The results of this paper show that a high consumption of cookies, sugar and processed
juices in children less than one year old is associated with maternal education. That
is, mothers with lower education levels feed their children more unhealthy foods.
We know that to improve complementary feeding, we need to understand the attributes
that mothers and caregivers ascribe to foods in their specific cultural setting. Another
important aspect to be considered is improving the availability and accessibility
of low-cost nutritious complementary foods. In addition, specific policies to regulate
the advertising of infant foods need to be adopted because it is known that advertising
influences the consumption of unhealthy foods.

Abbreviations

WHO: World Health Organization; EBF: Exclusive Breastfeeding; PPMA II: Second National
Survey on the Prevalence of Breastfeeding; CONEP: National Commission for Ethics in
Research; PNIAM: National Program to Encourage Breastfeeding; ENPACS: National Strategy
for Healthy Complementary Feeding; HBS: Household Budget Surveys.

Competing interests

All authors declare that there are no conflicts of interest to disclose.

Authors’ contributions

SRDM and SIV conceived the paper, conducted the analysis and interpretation of the
data, and wrote the manuscript. ACS, ALSC and MMLE contributed to the analysis, and
ERJG contributed to the design of the study and writing. All authors revised and approved
the final version of the paper for publication.

Financial support

This article is based on data from the Second National Survey of Prevalence of Breastfeeding,
which was conducted in state capitals and the Federal District during the second stage
of the multi-vaccination campaign in 2008 and supported by the Brazilian Ministry
of Health – Brazil.

Saldiva SRDM, Silva LFF, Saldiva PHN: Anthropometric assessment and food intake of children younger than 5 years of age
from a city in the semi-arid area of the Northeastern region of Brazil partially covered
by the bolsa família program.